Healthcare Provider Details

I. General information

NPI: 1184674830
Provider Name (Legal Business Name): SAN MARCOS MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1574 W BASE LINE ST
SAN BERNARDINO CA
92411-1736
US

IV. Provider business mailing address

1574 W BASE LINE ST
SAN BERNARDINO CA
92411-1736
US

V. Phone/Fax

Practice location:
  • Phone: 909-881-7320
  • Fax: 909-881-7330
Mailing address:
  • Phone: 909-881-7320
  • Fax: 909-881-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SANDRA GONZALEZ
Title or Position: COORDINATOR
Credential:
Phone: 909-376-4438